MEDICARE: ANNE C KOZEK, RD,MS,LDN YOUR CREATIVE NUTRITION RESOURCE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	164.001499	IL

General Provider Information

NPI Number	:	1659502284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANNE C KOZEK, RD,MS,LDN YOUR CREATIVE NUTRITION RESOURCE

Provider Business Mailing Address
First Line	:	2738 W 111TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-1832
Country	:	US
Telephone Number	:	773-429-9614
Fax Number	:

Provider Business Practice Location Address
First Line	:	2738 W 111TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-1832
Country	:	US
Telephone Number	:	773-429-9614
Fax Number	:

Authorized Official
Title or Position	:	DIETITIAN/OWNER
Name	:	ANNE CATHERINE KOZEK
Credential	:	RD,MS,LDN
Telephone Number	:	773-429-9614

Provider Enumeration Date	:	07/30/2009
Last Update Date	:	07/30/2009

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